Menu

University Policy

Sterile Processing

Policies

3364-139-1-01 Sterilization records

3364-139-1-02 Reprocessing and sterilization of surgical Instruments

3364-139-01-03 High level disinfection

3364-139-3-12 Utility shutdown
3364-139-6-12 Reprocessing of single-use items

3364-139-6-18 Sterilization of instruments received from non-UTMC source

Procedures and Protocols

General

SP1-1 Employee breaks

SP1-2 New employee orientation and training

SP1-3 Medical equipment inspection

SP1-4 Loaner trays

SP1-5 Case cart set-up

SP1-6 HLD testing and disinfection protocol

SP1-7 CVL instrument pick-up

SP1-8 Case cart missing items list

SP1-9 Call-off notification

SP1-10 Food and drink in work areas

Decontamination

SP2-1 Decontamination area

SP2-2 Decontamination of surgical instruments

SP2-3 Decontamination of case carts

SP2-7 Daily test for washer/disinfectors

SP2-8 Decontamination of reusable brushes

Sterilization

SP3-1 Peel pouches

SP3-2 Assembly and sterilization of instrument sets

SP3-3 Operation of steam sterilizers in sterile processing

SP3-4 BI and integrator process for steam sterilization

SP3-5 Computerized sterilization record management

SP3-6 Use of chemical indicators and integrators

SP3-7 Positive culture and recall of hospital items

SP3-8 Daily function tests for leaks and vacuum (Bowie-Dick Test)

SP3-9 BI Test for gas plasma sterilizers (STERRAD)

SP3-10 Operation of gas plasma sterilizers (STERRAD)

SP3-11 3+3 sterilizer test after maintenance

SP3-12 Loading of steam sterilizer Carts

SP-3-13 C41B rectal probe-MR fusion procedure

Last Updated: 12/5/25